There are roughly half a million beds in residential or nursing care homes in the UK.¹ Private providers operate almost all of these beds (90%) though the sector isn’t particularly lucrative: the average operator draws a profit of less than £5 per resident per day. Most beds are funded either in full (40%) or in part (10%) by local authorities. The NHS pays for a few (5%).

Central Government funding to local authorities was cut by 25% per person over the period of the last Government, though these cuts were not uniformly distributed across the country. This came on top of smaller reductions in funding over the previous five years. As a result, local authorities had much less to spend on social care. The number of day care places plummetted by 50% over a decade. About 20% fewer people received local authority funded care in their own home. And, partly as a result of this, the number of older people in residential or nursing care homes rose by more than 20%.

Over the next five years, we will see a perfect storm in social care for elderly people. The number of people aged over 75 is predicted to grow from 5.3 million today to 6.1 million in 2020 (a virtually unprecedented rate of increase, almost double what happened over the last five years). Yet Central Government funding to local authorities is to be cut further. Funding is being reduced while demand is predicted to increase more than ever before.

The burden will fall on the NHS, as it is in NHS beds that people often wait for care home places. The absurdity of this is that the average per-night cost of staying in an NHS hospital is three times greater than the average care home cost.

Yet there is another insidious factor imposed by Government which will push this situation from ‘substantial problem’ to ‘perfect storm’.

Most workers in residential and nursing care homes are paid minimum wage. By 2020, this will rise fromt £6.50 to £9.

Few could argue with giving hard-pressed workers a living wage. But given that average care home profits are less than 21p per patient per hour, care homes cannot maintain their current charges while increasing staff wages by £2.50 per hour. Yet they cannot raise their fees because Government cuts mean that local authorities can’t pay.

So what happens when care costs increase and funding decreases? First, care is cut: HC-One, Britain’s third-largest care home provider, is already training carers to take on highly skilled tasks which were previously done by more experienced and expensive nursing staff. But, since the cost of those carers is also increasing rapidly, this is only a stop gap solution. As Southern Cross, previously the UK’s largest care home provider, showed in 2011: care home providers can and will collapse.

As care home companies collapse, the supply of care home beds collapses with them. More elderly people get ‘stuck’ in NHS beds, at much greater cost to the taxpayer, and much greater risk to their own health.

And, to add extra thunderbolts to the storm, the number of NHS beds is decreasing rapidly: by nearly a quarter over the last ten years, with no sign of slowing. In this context, an increase in elderly people needlessly occupying NHS beds due to a lack of social care will cause the NHS to grind to a halt.

The underlying problem here is that the Government fails to understand that protecting NHS funding does not protect NHS services. Health and social care are two arms of the same beast: cutting one leaves the other with more to do. Yet the long-term solution isn’t obvious: there are limits to the burden of tax people are willing to carry to fund health and social care services.

The forecast is for bigger storms ahead.

I tweeted about this Times article yesterday – it’s really brilliant, like the plot of an off-beat West Wing episode.

Julian Glover (formerly of The Guardian) writes the following for Mr Lansley:

As I grew up, the NHS wasn’t some remote organisation. It was what we knew, what we cared about and what we wanted to make work. And that is every bit as true today. As a son, as a father, and as a patient, I know what it is to have the NHS at your side.

It is returned from Lansley’s office as:

Outcomes depend on integration across services. Opportunity of NHS/public health/and local authorities together. Like they do in Sheffield … Not structural integration but integration around families and children. Marmot (universal proportionalism) – early intervention.

Go and read the full thing, it’s fantastic.

The first argument against the Bill is that we don’t need legislation. Those who articulate this argument all of a sudden should be asked why, then, do they oppose it?

Because it isn’t needed, perhaps? This utterly bizarre defence of the Health and Social Care Bill by Baroness Warsi is car-crash online commentary. It’s poorly informed and logically flawed.

With friends like these, does the Health and Social Care Bill even need enemies?

Five reasons why this video (whilst it makes an important and valid wider point) irritates me:
1. It doesn’t acknowledge that both A (on the left) and B (on the right) are both, ultimately, working for profit rather than purely for the benefit of patients.
2. It doesn’t acknowledge that A likely employs salaried doctors like B, with similar issues.
3. It doesn’t acknowledge that since A opted out of providing out-of-hours care, B has stepped in to provide it. In fact, it’s B who’s illustrated at walking out at the end, just when B’s colleagues are kicking into action.
4. It suggests that non-partner doctors hold less professionalism, and are less concerned with patient welfare. Such doctors include many GPs, as well as virtually all secondary and tertiary care physicians and surgeons.
5. It doesn’t acknowledge a single advantage of the corporate model. A’s approach may well be preferable as a whole, but B’s approach is not without merit, and it’s idiotic to suggest that it is.

This #nhsreform mythbuster from DH is overtly party political (“we will never, ever privatise the NHS”).

I’m not comfortable with statements which are so clearly partisan being ascribed to DH, and I’m surprised the Civil Service didn’t prevent it. Such bodies shouldn’t be political puppets.

Also, some of the “myths” are blatantly not “myths” – e.g. “You are introducing competition in the NHS”

This has really got me riled – and I’m not the only one.

Andy Burnham has written a piece for today’s Guardian announcing that

For Labour, it all comes down to defending the N in NHS … By contrast, the Tories are ambivalent about the role of the centre, preferring localism in health as in other areas.

It’s probably churlish of me to point out that Mr Burnham has previously espoused about the paramount important of locally, rather than natioanlly, influenced healthcare (“The hospital and Primary Care Trust must listen to patients and local people and involve them in shaping the future of the hospital” – hardly a nationalistic approach).

To point him in the direction of the Conservatives’ 45-page Green Paper on the NHS in response to his claim that “on health, Cameron doesn’t do detail” would probably be missing the point.

And let’s just ignore Mr Burnham’s complete lack of insight into the effect of his target-driven culture – Patients being moved like pawns around a hospital-sized game-board to avoid staying in one place for too long – regardless of their clinical need.

Let’s just park all of those thoughts in the vastly overpriced hospital multi-storey, and concentrate on his main point. The ‘N’.

I’m an ardant supporter of the broad principles of the NHS. I think healthcare free at the point of need is a wonderful thing. But I don’t subscribe to Andy Burnham’s ideology of a national health service with national targets to tackle national problems.

The residents of Byker have different healthcare needs to the residents of Mayfair, and the needs of the residents of Tunbridge Wells or Toxteth differ equally again. Whilst it’s true that residents in none of the above places would relish waiting more than four hours in A&E, such meaningless targets do little to disprove the inverse care law which appears to be Burnham’s prime argument for focusing on the ‘N’.

In fact, quite obviously, the most imporant bit is the ‘HS’. The country needs a Health Service that is adaptable to the needs of all. Different locales will, necessarily, have different priorities. Giving Respiratory Medicine the same priority in the North East (where lung disease is relatively common) and in Southern England (where it is rarer) would appear to me to be a failing of a nationalised system, not a benefit.

Targetting outcomes seems eminently more sensible – The respiratory services in the North-East and the South don’t need to be equitable, provided the outcome – measured in cure rate, death rate, or howsoever seems most sensible to the respiratory physicians who are far more intelligent than me – is equitable.

That’s the kind of Health Service I would like. One with an ability to respond to the local health needs of local people – not by “national standards, national pay and national accountability” – all three of which have everything to do with bureauocracy, and nothing to do with healthcare.